AB 68, as amended, Waldron. Medi-Cal.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Covered benefits under the Medi-Cal program include the purchase of prescribed drugs, subject to the Medi-Cal List of Contract Drugs and utilization controls.
This bill, which would be known as the Patient Access to Prescribed Epilepsy Treatments Act, would require, to the extent permitted by federal law, that any drug in the seizure or epilepsy therapeutic drug class would be a covered benefit under the Medi-Cal program. The bill would require a Medi-Cal managed care plan to provide coverage for these drugs, regardless of whether the drug is on the plan’s
formulary, if the treating provider demonstrates
begin delete that,end delete in his or her reasonable, professional judgment, the drug is medically necessary and consistent with specified federal rules and begin delete regulations. If the managed care plan elects not to cover a drug described in the bill, the drug would be deemed a noncapitated benefit not reimbursed by the managed care plan, which would be available on a fee-for-service basis, and the plan’s contracted rate would be reduced to reflect the cost to the state of providing the benefit to the patient, as specified. This bill would declare the
intent of the Legislature that a prescriber’s reasonable, professional judgment prevail in prescribing the drugs described in the bill to Medi-Cal patients.end delete
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
This act shall be known, and may be cited, as the
2Patient Access to Prescribed Epilepsy Treatments Act.
Section 14133.06 is added to the Welfare and
4Institutions Code, to read:
(a) It is the intent of the Legislature in enacting this
6section that a
begin delete prescriber’s reasonable, professional judgment prevail
7in prescribing to Medi-Cal patients any drug in the therapeutic
8drug class that includes drugs approved by the federal Food and
9Drug Administration for use in the treatment of seizures or
10epilepsy, but are not on Medi-Cal managed care plan formularies,
11or are subject to prior authorization requirements.end delete
18(b) To the extent permitted by federal law, if any drug
begin delete in the described in subdivision (a) is prescribed
19seizure or epilepsy therapeutic drug classend delete
21by a Medi-Cal beneficiary’s treating provider, that drug shall be
22a covered benefit under this chapter.
begin deleteExcept as provided in subdivision (d), and notwithstanding if the
24the establishment of a statewide outpatient drug formulary, a
25Medi-Cal managed care plan shall provide coverage for a drug in
26the seizures and epilepsy therapeutic class, as described in
P3 1subdivision (a), regardless of whether the drug is on the plan’s
2formulary, end delete
3treating provider demonstrates, consistent with federal
begin delete law that,end delete
4 in his or her reasonable, professional judgment, the drug
5is medically necessary and consistent with the federal Food and
6Drug Administration’s labeling and use rules and regulations, as
7supported in at least one of the official compendia identified in
8Section 1927(g)(1)(B)(i) of the federal Social Security Act (42
begin delete 1396r-8(g)(1)(B)(i)).end delete
11(d) (1) If a Medi-Cal managed care plan elects not to cover a
12seizure or epilepsy drug described in subdivision (b), the drug shall
13be deemed a noncapitated benefit not reimbursed by the managed
14care plan, and shall be available on a fee-for-service basis. The
15treating provider shall follow fee-for-service billing instructions
16for reimbursement under these circumstances.
17(2) If a drug is deemed a noncapitated benefit not reimbursed
18by a Medi-Cal managed care plan, as described in paragraph (1),
19the plan’s contracted rate shall be reduced to reflect the cost of
20providing the benefit to the patient on a fee-for-service basis.